Rheumatoid arthritis is a disease often seen and treated in the physical therapy setting. This article, written from the point of view of a physical therapist, provides an overview of the disease, the prognosis for those afflicted, and common treatments.

What is Rheumatoid Arthritis?

Rheumatoid Arthritis (RA) is a systemic autoimmune disorder of unknown etiology. Autoimmune diseases are illnesses that occur when the body tissues are mistakenly attacked by its own immune system. The major distinctive feature is chronic, symmetric and erosive synovitis of peripheral joints. The severity of the joint disease may fluctuate over time but the most common outcome of established disease is progressive development of various degrees of joint dysfunction, deformity and disability.

image credit – cloudsoup

Who Does Rheumatoid Arthritis affect?

This systemic disease affects 1-2% of the adult population in every part of the world. RA affects more than two million Americans. RA increases with age for both men and women. Peak onset is 20-45 years of age. Prevalence is higher in women. More than 75% of people with RA are women. Rheumatoid factor is found in the serum of approximately 85% of people with RA.

How does Rheumatoid Arthritis affect the body?

The joint inflammation initially starts in the synovium (a thin layer of tissue which lines the joint) which eventually can lead to cartilage destruction. The cartilage damage results in joint space narrowing and resulting bone and joint damage. Synovitis is potentially reversible and is often dealt with pharmacologically and by other non-surgical means. Synovitis tends to follow a sine wave pattern with fluctuating symptom severity. Active synovitis is represented by warm, swollen, obviously inflamed joints. The joints affected are usually superficial joints with easily distensible capsules such as the knee, wrist and finger joints. Structural damage typically begins within the first and second year of the disease. It is characterized by cartilage loss and erosion of periarticular bone. This process is irreversible and progresses as a linear function of the amount of prior synovitis. Remission usually occurs in the first two years of the disease

What are the signs and symptoms of the Rheumatoid Arthritis?

According to the American College of Rheumatology, four of the seven symptoms indicate a diagnosis of RA.

1. Morning stiffness lasting more than 1 hour, present daily for more than 6 weeks.
2. Arthritis of 3 joints lasting for at least 6 weeks.
3. Arthritis of hand joints lasting for at least 6 weeks.
4. Symmetric arthritis lasting for at least 6 weeks.
5. Rheumatoid nodules.
6. Positive Rheumatoid Factor on blood tests.
7. Joint changes on x-ray.

What Joints are typically involved?

Joint deformities in RA are a result of the synovitis involved with the disease as well as pannus (granular tissue) formation within the joint. Cartilage and bone damage result from this chronic inflammation. The patient’s attempt to avoid painful positions leads to posturing the joint in the least painful position. Resulting joint deformities include:

• Joint immobilizations
• Muscle spasm and shortening
• Bone and Cartilage destruction
• Ligament laxity
• Altered tendon function

Commonly affected joints:

• Cervical Spine
  • frequently involved.
  • neck stiffness
  • general motion loss
  • C1-C2 instability due to tenosynovitis of Transverse ligament
• Shoulder
  • presence of swelling often not detected.
  • motion loss is observed – Frozen Shoulder Syndrome
  • symptoms worse at night
• Elbow
  • easiest to detect.
  • flexion deformity common  
  • Ulnar nerve neuropathies may develop

• Hand /Wrist/Fingers
  • almost all patients with RA have hand, wrist, MCP (metacarpalphalangeal) and PIP (proximal phalangeal) involvement.
  • ulnar deviation of MCP
  • radial deviation at wrists
  • Swan-neck deformities
  • Boutonniere deformities
  • “Z” deformity of thumb
  • rheumatoid Nodules along tendon sheaths
  • nodular thickening along flexor tendons of the palms
  • tendon Ruptures – most common Extensor Pollicus Longus
• Knee
  • effusion and synovial thickening
  • Baker’s cyst
  • Flexion with valgus and external rotation tibia, posterior subluxation of tibia   
• Hip
  • initial dysfunction usually difficulty putting on one’s shoes and socks
• Foot & Ankle
  • lower extremity involvement leads to greater dysfunction and pain due to weight bearing role
  • widening of forefoot (Metatarsophalangeal) joints
  • dropping of metatarsal (MT) heads
  • distal displacement of MT fat pads
  • lateral deviation of 1st toe
  • claw or hammer toes
  • pronation and eversion of foot
  • tarsal tunnel involvement resulting in burning paresthesia       

What other extra-articular effects are common?

1. Generalized Malaise
2. Weakness
3. Flu-like symptoms, including a low-grade fever
4. Rheumatoid Nodules (20% of cases)
5. Positive Rheumatoid Factor
6. Cardiac – inflammatory pericarditis
7. Anemia
8. Respiratory- inflammation of cricoaryteroid joint, laryngeal pain, dysphonia, pain on swallowing
9. Vasculitic lesions
10. Vision Loss – Scleritis (inflammation of blood vessels in the eye)

What is the prognosis?

Prognosis of Rheumatoid Arthritis is uncertain due to the prolonged nature of the disease, its variability among people affected as well as the difficulty in defining the milder and subclinical forms of the disease.

Factors that may predict a more severe and persistent course of disease

1. Presence of RH factor
2. Presence of nodules
3. HLA-DR4 haplotype (genetic marker)

What is the Treatment for Rheumatoid Arthritis?

The aim of treatment is to provide pain relief, decrease joint inflammation, maintain or restore joint function, prevent bone and cartilage destruction, and to maximize quality of life. Aggressive and early rapid control of inflammation is now the common approach to therapy. Current guidelines recommend that the majority of patients with newly diagnosed RA should be started on DMARD therapy within three months of diagnosis.

1. Education – understanding the disease, management of symptoms
2. Rest and exercise -Physical Therapy helpful to manage a good balance
3. Joint protection – splints, braces, supports, assistive devices
4. Diet – fish oil supplements containing omega-3 fatty acids help reduce inflammation
5. Medication
   • NSAIDS (non-steroidal anti-inflammatory drugs) – these drugs decrease joint inflammation and pain. They will help improve joint function by providing analgesic and anti-inflammatory effects. Unfortunately, these drugs do not change the course of the disease or joint damage and, generally should not be used as the sole treatment for RA.
   • SAARDS (slow-acting antirheumatic drugs) / DMARDS (disease-modifying antirheumatic drugs) -these drugs are the only ones that have been proven to control or slow the progression of the RA disease process. Methotrexate is the preferred and most common agent chosen for initial therapy.
   • Biologic response modifiers – drugs that interfere with the autoimmune response in RA
   • Prosorba Column – mechanically removes inflammation antibodies from the blood
   • Oral Corticosteroids – proven to be useful for symptom relief and appear to slow the rate of joint damage in RA. Long-term use can have adverse effects on the patient and therefore limits their use in RA.
6. Topical pain-relieving creams, rubs, sprays
7. Hot/Cold
8. Surgery – most commonly performed on the knee, elbow and shoulder joints

References:

1. Guidelines for the management of rheumatoid arthritis. 2002 update. American College of Rheumatology Subcommittee on Rheumatoid Arthritis. Arthritis Rheum 2002; 46:328-46.
2. Carruthers-Czyzewski P. A holistic prescription for rheumatoid arthritis. CPJ 1998; 131:35-9.
3. Choy EHS, Scott DL. Drug treatment of rheumatic diseases in the 1990’s: achievements and future developments. Drugs 1997; 53:337-48
4. Reddy I, Robinson B, Khan M. Rheumatoid arthritis: symptoms, diagnosis and clinical management. Drug Store News 1998; 20:27-31.
5. Lacaille D. Rheumatology: 8. Advanced therapy. CMAJ 2000; 163:721-8.
6. http://www.apotex.ca/En/ProfessionalAffairs/CEEssentials/Modules/ar/risk_factors_ra.asp

You may also be interested in:

• Raynaud’s Syndrome
• Introduction to Osteoarthritis of the Knee
• What is Rheumatoid Arthritis – Infographic